Opioid Addiction and Utilization Review: The Information Gap Must Be Addressed

Does the workers’ compensation industry create addictions? Requests for drugs are increasingly going through utilization review (UR) because the healthcare industry has become more aware of the risks of opioid treatment. Doctors prescribe opioids, such as oxycodone, hydrocodone, morphine, and others, to treat moderate to severe pain. People can become addicted to opioids, and both intentional and unintentional overdoses are not uncommon.

For doctors and UR providers considering the appropriateness of opioid treatment, a lack of information makes it difficult to get the full clinical picture when establishing medical necessity.

Prescription Drug Monitoring

Many states in the U.S. have implemented database programs to monitor prescription narcotics. Doctors report their prescription patterns and can check to see if patients are doctor shopping – going to multiple doctors to try to get more narcotics prescribed than is medically necessary — and ensure patient safety through accurate reporting of actual drugs and combinations of drugs. These databases are important tools for doctors looking to ensure the safety of patients while potentially preventing or combating opioid addiction.

Prescribing doctors know the patient’s medication history by definitively knowing what they have prescribed and what the patient divulges taking from other sources. Another valuable source for medication history is the prescription monitoring databases. Although there may be reporting requirements in some states, even these databases do not provide the entire medication history and may have gaps skewing the potential total medication history. Regardless, any available history within these databases is key to a complete patient record.

Peer reviewers who are the gatekeepers between prescribers and payors have a duty to make independent decisions regarding the medical necessity of proposed drugs. Due to regulations including HIPAA, these UR providers do not have access to these extremely valuable databases; only prescribing doctors have access to this prescribing history. Peer reviewers have no way of knowing, for example, how long a patient has already been taking a drug across different medical providers, perhaps for years. UR can only address whether or not the drug would be appropriate at that specified time from the history of that one prescribing doctor for that particular diagnosis, without the benefit of patient history.

When healthcare providers submit requests for opioid prescriptions, UR peer reviewers must operate without access to this important information which could reveal safety concerns related to the patient’s medication regime.

HIPAA regulations are vital in ensuring patient information is protected, however opening the drug monitoring databases to UR providers would make it easier to avoid prescribing opioids to people who do not need them or people for whom it would create a safety concern for their overall health.

With access to the prescription drug databases, UR would have more sufficient information to prevent inappropriate use of opioids. Not only would this save costs, but also reduce the need for costly addiction treatments, and perhaps even save lives.